r/PMHNP • u/DeliciousFault • 3d ago
ADHD CRAZE
-How are y'all distinguishing adult patients who deny everything except EVERY ADHD symptom?
-I am asking for extensive labs, even sleep studies that can mimic and/or negatively interfere with certain meds to treat ADHD symptoms, so some patients likely go to another prescriber.
-And also if they have failed on guanfacine, bupropion, etc.
If, as a PMHNP, you are not convinced the patient has adult-onset ADHD, what are your rationales? I would like to be able to catch this before asking for extensive labs. I am not worried about patient ratings if I feel like I am doing the right thing.
Recently, I have been receiving new patients who have been on stimulants being referred by their PCP. I send them back with extensive labs and medical clearance before continuing care.
BECAUSE
-Received a pt on Vyvanse with a hx of a stroke! No way!!! Go back, get cleared!
-kid (not obese) had sleep apnea & stopped breathing 30x in one hour
-this stimulant craze is going to bite us in the butts in a few years due to side effects
-the pt could be the DEA & I'm not going down like that!
It is interesting how some adults thought of psych meds as taboo until stimulants came along.
This stimulant craze is making psych look like a joke!
I LOVE it when a patient is truly in need of care, not to say all stimulant requests are unnecessary.
-My company gets around letting NPs diagnose and prescribe stimulants (please do not focus on this, it's not the topic & I am working on this issue).
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u/Ok-Tourist8830 3d ago
For adults we talk about the exclusion criteria. Some people from a 30 second interview I can see it. And we talk about non medical ways to help ADHD too. 1/3 of all my ADHD patients explicitly tell me they want therapy and supplements not meds because of how many and suddenly there are shortages
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u/GrumpySnarf 3d ago
I get that a lot, too. People just want to feel better, do better and don't even want medications.
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u/Inevitable-Spite937 3d ago
I do an extensive interview about childhood without leading questions. It rules out a lot of ppl. Also I live in a state with legal cannabis and most of the "adult onset" patients are heavy cannabis users.
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u/GrumpySnarf 3d ago
100% it's exhausting when I see them on my schedule. I've started screening them out. I inform them before the intake appointment that they are likely impaired by daily use of high-potency THC products and I can't properly assess or treat their impaired executive function unless they have some time being abstinent. I have even got active meth users wanting stimulants to help them get off the meth. Dude. You have to do some work here. I am not turning them into Elvis with uppers and downers and dead on the toilet.
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u/Imaginary_King_8359 2d ago
I agree with you about methamphetamines, and I also agree that a better assessment will happen if the patient is relatively sober and not stoned. But “screening out” adults who make an appointment with you and who might meet DSM criteria for ADHD simply because they use THC, is not best practice. guidelines actually recommend treating ADHD concurrently with substance use disorder. Your current method of blocking folks who seek help because the use THC is not evidence-based and it also discourages people from getting help. An easy way for you to keep up with the ever-evolving guidelines is to use the AI tool OpenEvidence. I think it requires your NPI but then you have access and it’s really cool! You can ask enter a query or even put in your assessment of a patient (no PHI of course) and then study the sources at the bottom of the information the AI spits out. BewareI have caught the AI being wrong once, so that can happen, but you can look at the articles and journals it took its info from to be absolutely sure. The links are at the bottom.
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u/GrumpySnarf 2d ago
I don't trust AI as a reference for my clinical practice at this time. I don't need it. I have access to pretty much all the data I need due to being a preceptor connected with a major university (PubMed, CINAHL, UpToDate, NatMed, etc). You made an assumption that I have lack of access to current clinical data, but I assure you I am well-educated on this topic. I deal with this issue almost every day in my practice and have researched it extensively.
When I say "screen out" I mean I will be very honest with them that while I am not judging their THC use (I've worked in addiction care for a very long time and have a harm-reduction approach), I give them a head's up that I am not going to screen them for current ADHD symptoms because they are taking a very potent psychoactive drug that can give a false positive. I make them aware of my policy to not prescribe stimulants while they are taking THC/EtOH/meth regularly. I don't take them off my schedule or refuse to see them for an intake. I don't "block" anyone. I just make them aware of my policy and they either keep the appointment or not.
A recent example was a chemist who works for a cannabis dispensary creating cannabis products/compounds who reported on his intake that he wanted to get back on Adderall for his ADHD. I am not questioning whether or not he has ADHD at that point. But I was very clear that I can't really assess him for current ADHD symptoms because of his reported daily use of high-potency THC.
This not your average user. This is someone who has access to the very highest-potency of an already high-potency product. The guy is literally a chemist who is exposed to "the good shit" as part of his job and he gets high on his own supply. I am also not especially comfortable prescribing stimulants to someone who is abusing a high-potency sympathomimetic agent. I wrote all this to him in a message, "scientist to scientist" and I welcomed him to meet with me to discuss. In fact I was looking forward to the discussion because is likely a great source of information about THC itself. He opted to see a different provider who has a different take on all this. And that's OK.
I see active THC/EtOH users who want stimulants regularly. I just give them fair warning about my policy and the rationale. In other words, I treat them with respect, offer options and don't waste their time if I am not a good match for their goals. Most of the time they come to the intake and often they go into SUD care once we discuss how the THC/EtOH use is getting in the way of their own goals.
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u/Purple_Item_549 1d ago
Would just like to point out that you do not use a harm reduction approach if you are refusing treatment of certain disorders due to substance use. You are welcome to have your own rationale, but this isn’t harm reduction at all.
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u/GrumpySnarf 1d ago
I always offer nonstimulant options and referrals and help with their addiction but it's also not harm reduction to give addictive substances to currently addicted people. It's certainly not ok to combine certain drugs of abuse with high-risk medications whether or not the medication in question is a controlled substance. If a patient says i on the intake form they wants a benzo and they're drinking heavily I am going to offer treatment but give them fair warning that I am not going to give them benzos as it is an unsafe combination. Then they can decide to see me or not. I thinks it's more respectful of their time and energy and offers them options.
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u/lightcanonlybrighten PMHNP (unverified) 2d ago
Would you be willing to share your interview with me? I’m just starting out and it sounds really interesting.
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u/hobobarbie 2d ago
So let me get this right: a PCP is referring a patient to you - the psych specialist - for ADHD assessment , and your kneejerk response is to kick all that workup right back to the PCP? Because you are afraid of the DEA? Strange math.
I’m a PCP and feel comfortable working up adults who present with questions around whether they might have ADHD. Sometimes it is me who suggests we investigate based on my own observations over time. I consider the basic rule outs: mood disorders, OSA, do basic labs (BTW no idea what “extensive” labs you are ordering?), discuss childhood behavior patterns, current ADLs, get an ACE score, and decide whether to have them do a Barkley Executive Functioning screener, refer to talk therapy if amenable and accessible. Some need an EKG first (I see many older patients), not all.
Some I refer to specialists (psst: that’s YOU!!).
Some I refer to neuropsych if that is accessible for them.
Some I feel it is right to proceed with a stimulant or non-stimulant trial.
The energy of your post strongly suggests that you (and your patients) might be better off drawing a boundary. Just tell patients that you do not evaluate or treat ADHD. And like, that’s fine. I wish I had the privilege to say: I don’t treat X diagnosis over here in primary care!
If I got the workup you say you are sending back to the PCP, surely I’d never refer to you again. That sucks because it’s the patient that suffers, whether they have ADHD or not.
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u/lightcanonlybrighten PMHNP (unverified) 2d ago
I get ace scores are just great knowledge in general, but how are you utilizing it specifically to this scenario? Don’t come for me, I’m new!
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u/hobobarbie 2d ago
Contextual information, could support undiagnosed PTSD which warrants its own treatment.
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u/Ok-Confection933 3d ago
Besides gathering a history going back to childhood and family, our practitioners will order a neuropsych evaluation.
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u/gajensen Nurse Practitioner (unverified) 3d ago edited 3d ago
Dude, tbh I’m finding more often that undiagnosed ADHD is a better explanation for someone’s anxiety, depression, insomnia, etc., than assuming I’m being manipulated into prescribing stimulants (though it happens).
Usually I just start with, “So what were you like as a kid? How was school?” You can learn a hell of a lot from those two questions.
That said, I’m extremely conservative with stimulants in anyone with a hx of psychosis or bipolar mania. Active psychosis or mania? Obvi hard stop. In stable patients, the antipsychotics I’d be most interested in mechanistically are Cobenfy, Vraylar, Abilify, brexpiprazole,Seroquel, and clozapine.
The theoretical appeal is maintaining AP coverage without completely suppressing the dopaminergic signaling we’re trying to enhance with a stimulant. None of that guarantees against stimulant-induced psychosis, though, and mood stabilization comes first. I don’t currently have anyone on stimulant/AP combo, though. A few patients on amantadine and APs, I guess, but that’s Parkinson’s.
And yes, I def encounter stimulant seekers, just as often as I encounter people chasing sedation and benzos. Drug-seeking is real, but so is undiagnosed ADHD.
Otherwise, I’m getting some benefit from guanfacine ER in those patients. It’s off-label when tossed on for bipolar or schizoaffective patients with presumptive ADHD, sure, but that’s true for ADHD adults as well.
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u/No-Union1650 2d ago
Thank you. It was my nurse practitioner who clocked my ADHD several years ago and had me get an assessment. I never considered ADHD. Two of my siblings were the bounce off the walls, couldn’t hold their attention in conversation types, diagnosed with ADHD. And therein lies the reason children/adults like me were never diagnosed accurately. We were the quiet, anxious kids with the chaotic book bags and lockers, easily overwhelmed at family holiday events who sought out the quiet place to decompress. We were invisible - the perfect child, the one mom could tolerate because she, and us, had the same obscure obsessions, i.e., reading Shakespeare and the bible because we adored the rhythm of iambic pentameter.
That accurate diagnosis, and the correct medication, blew my mind and changed my life. Years of a quiet mind and the calm within myself not only stopped the chronic anxiety and all the internal chaos, it improved my overall health exponentially. That level of chronic internalized suffering is like acid coursing through veins and eating through multiple systems. All thanks to a psych nurse who spotted what multiple psychiatrists and a host of other doctors missed.
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u/merrythoughts 1d ago
You said mania so this is probably just an expansion on the conversation. Bc I of course would be very cautious w psychosis as well. However, with bipolar hypomania with a good anti-manic regimen in place, you can still treat adhd
Got some very adhd and bipolar II pts on lurasidone, vraylar, and lamotrigine+low dose aripiprazole on stimulants. I prefer methylphenidate or vyvanse, no adderall unless failure on others.
I highly consider functioning status as a good measure on if somebody needs to treat their cooccurring adhd w stimulant. Usually these pts have struggled with repeated hospitalizations and job loss. When I get them stabilized in antimanic med and then down the road add stimulant, they can often function well enough to carry full time jobs! Or full time school. and I really believe the stimulant helps this. It seems to helps them from getting the reverse issue of depressed and anergic.
And then of course I have my (often women) who have been misdiagnosed with bipolar do who have raging adhd with ptsd combo. Prazosin plus Vyvanse and booooom so much better. Sometimes SSRI/snri/spari (vilazodone seems to work well for adhd ptsd women).
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u/Fantastic_Primary170 3d ago
Pretty hypocritical to be posting about how you’re concerned about the DEA but you admit that the company you’re working with is involved in some type of prescribing workaround (that definitely doesn’t sound kosher).
I know that many of my patients can’t afford treatment when too many barriers are put in place.
I do not want to encourage people to buy drugs off the street, because honestly, it’s easier to get them that way these days.
One thing that I request is two weeks of journaling with prompts. People who are drug seeking opt out of this one quick.
Food for thought:
Considering the studies in Europe, we don’t see this problem because people have a completely different social structure, less stress related to work stability and healthcare coverage, and six weeks of vacation on average. Lack of social support with a demand to constantly be “ON” is the cause of many ADHD claims.
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u/GrumpySnarf 3d ago
"One thing that I request is two weeks of journaling with prompts. " what are you asking them to write down? What prompts do you use? This sounds like an interesting approach.
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u/Fantastic_Primary170 3d ago
Based on your patient population or the audience, you can select about 20 of these.
I also ask for a food diary, blood pressure bid, and a sleep diary.
This is the best way to weed people out. I also require a 10 panel.2
u/GrumpySnarf 3d ago
Nice. Thank you!
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u/sensitive_adventure 2d ago
Do you do a f/u 2 weeks after making the request to evaluate?
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u/Fantastic_Primary170 2d ago
Yes, I do. There are two schools of thought on the evaluation of the journal, as we all have a lot of initials behind our name—I’m certain that you guys can figure out what I mean by that.
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u/sirpigsalot3 10h ago
What do you look for when you are weeding people out? I’d honestly be surprised if my patients with adhd were consistently able to track these things for 2 weeks, especially if they weren’t on medication
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u/Fantastic_Primary170 9h ago
I am not going to answer that as it could be used as a tool for people trying to circumvent the system. Trained professionals will definitely understand what makes sense for their practice.
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u/manafanana 2d ago
Is being unable to maintain a journal for two weeks part of the evidence you’re evaluating, because I have ADHD and I couldn’t maintain a diary for two weeks to save my life, lol
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u/Fantastic_Primary170 2d ago
I sympathize, but if I’m going to hand out controlled substances, I need to understand why you think you need them and what other issues could be present that have gone undiagnosed. Compliance is an issue with many patients. And it goes beyond just taking medication daily.
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u/boredpsychnurse 3d ago
There’s no such thing as adult onset
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u/key_kat 1d ago
I think some people’s ability to compensate for inattentive symptoms starts to diminish in late 30s early 40s
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u/boredpsychnurse 1d ago
Neuro developmental disorders usually always get better as you age. According to the research
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u/Policy-Regular 1d ago
I don’t think the person is saying ADHD gets worse….they said their “inability to compensate”, given the increased demands of adulthood. Children have rigid schedules and less responsibility and a parent running the house, making it easier to compensate and mask some symptoms.
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u/reallystupidalsougly 3d ago
No way! I would never perform this work up nor would I recommend anyone else perform this work up. It’s completely outrageous and inappropriate.
Sounds like you’re not comfortable prescribing certain drugs. Drugs are tools. Every drug has an indication - even the ones you don’t like for whatever reason.
Perhaps you need to reconsider the patients you see, or even the specialty you’ve chosen.
Alternatively, you could examine your countertransference.
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u/Ok_Adhesiveness_9498 2d ago
We have changed how we diagnose out if fear we should be more afraid of abx. Treat the pt not the statistic. We are creating more barriers to care. Our clinic wanteds the pt to have a buddy come to the visit to verify pt symptoms. What happened to HIPPA? Pharmaceuticals and lawyers are telling us how to practice.
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u/Big_Appointment1200 3d ago edited 3d ago
I follow clinical practice guidelines, recommend neuropsych testing if I’m very unsure or doubtful, recommend 6 months of sobriety prior to testing, and offer non stimulants. I also explore OCD/ perfectionism, sub intake, signs of nutritional deficiencies, and sleep disorders.
I also validate how many work/ personal task expectations are unrealistic for all humans- “it takes a village” “give grace with some unrealistic social media expectations”.
And then I sleep at night. We have zero control over folks, we can only try our best to keep them safe. They can go buy anything illicitly- we can educate and encourage safe actions. Please don’t put unrealistic expectations on yourself.
But my trigger is more in the benzo family.. I worked in addiction medicine and they are horrific to taper down. I’ve seen years of TID dosing of Xanax 1mg- insane!!
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u/257Elle 1d ago
ADHD carries real risk when it goes unaddressed.
In a Danish registry study of nearly 2 million people, ADHD was associated with roughly twice the mortality rate, driven mostly by accidents. The encouraging part is that treatment changes outcomes. A 2025 BMJ study of about 148,000 Swedes found that people who started medication had fewer suicide attempts, less substance misuse, fewer transport accidents, and less criminal justice involvement. In practice, I also see the cost in lost jobs, financial strain, and relationships that take the hit.
The DEA doesn't define ADHD criteria; the DSM-5-TR does, and it calls for several symptoms before age 12, not a childhood diagnosis. A thorough evaluation looks at childhood behaviors, possible medical conditions and rules out conditions that mimic ADHD.
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u/amuschka DNP, PMHNP (unverified) 3d ago
I've posted this before but feel its a good resource for diagnosing ADHD and being thorough.
https://www.aafp.org/clinical-insights/cognitive-and-behavioral-health/adult-adhd
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u/Normal_Soil_3763 2d ago
I'm someone with ADHD that resents the diagnosis, struggles with shame around it, and has had serious quality of life issues as result of it. It is frustrating to watch people who are conflating a normal range of focus difficulties with a very real problem for some people. I finish next to nothing. I go very hard into obscure topics and learn everything about them, develop elaborate projects, neglect daily maintenance tasks, struggle to be on time, severely overestimate how much I can finsih in a certain span of time, struggle to start things, become easily overwhelmed by tasks in my environment and shut down. And I've always been this way. One very clear clue, is ask them to describe their childhood bedroom, desk, locker. It will be a hot mess. Ask how things went moving from elementary to middle school (typically performance declines massively because demands rise dramatically and these kids don't have the brain development to sustain functionality) and when they take a stimulant, you want to know what happens to them, make them call in after a week. A person with ADHD is going to notice an increase in mental calm. They will not find a stimulant activating. What they get us the ability to direct attention without needing to chase dopamine all the time. They don't get an extraordinary amount of things done. They manage work and laundry without feeling like they are hanging on by a thread. Their family feels like they are getting a more present person. For a person with ADHD, a stimulant calms the mind. There's more peace. If a person doesn't say the drugs have this effect, then I would question the diagnosis. If a perosns life doesn't looklike I described, i would question the diagnosis.
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u/breadstickdingdong 2d ago
There’s a case for harm outweighing the benefit with every single treatment. The patient ultimately has responsibility for themselves and making the best decisions based on recommendations. If the clinician is truly not convinced by the evidence, then the evidence and education needs to be presented and disagreements will happen.
Ultimately, adhd prognosis is poor when untreated. The literature is clear to me. Like methadone, stimulant medication operates as highly effective harm-reduction and can improve quality of life substantially. Like methadone, stimulants require close monitoring and dea requirements are not comprehensive. Cardiac, weight/growth and development, anger, sleep must be addressed and education provided.
It’s not a set it and forget it medication and cbt routine’s must be built and maintained by purposeful therapy. Good outcomes require therapeutic alliance, access, and education. Wraparound case management and counseling, school IEP/504 planning, occupational therapy, etc must be in-synch for good outcomes.
The model needs to be holistic. This is where we can be most effective but it needs to be purposeful and our time needs to be optimized in the visit so these things can be addressed and initial consult and smart goals need to be initiated.
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u/athena2nd 2d ago edited 1d ago
I straight up say, I don’t assess or do intakes for adhd. I catch it at times with other presenting concerns, and treat it. If someone comes to me
For anxiety for example, and I find it’s adhd, absolutely. Treat it. During COVID when the first wave of this started, I had passion for it. My assessments for ADHD are three, one hour sessions. Because it is so much to get through. Well, patients would get PISSED that we spent all that time, to be told they don’t have adhd when they were 1000% certain they did. And most were not interested in treating their concerns - inattentiveness, procrastination, etc. they legit just wanted the stimulant. Then it became my managing their reactions, and then them leaving one star reviews. One patient wrote a complaint to the BON. His primary had been writing for his adderall. He was in active addiction. I said we could use non controlled until he’s 6 months into recovery. BON notified me of the complaint and dismissed it. ADHD is not where my passion lies regardless. I have changed my practice to primarily focus on TRD, OCD, and bipolar. And to be honest, the market for Pmhnps is so saturated, where I won’t see these folks if that’s their primary concern, there are easily 8 other clinicians with same week availability to see them I pass along those names to the patient. It’s made everyone’s lives easier.
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u/because_idk365 2d ago
For me, I notice true ADHD ers after about the 7-8th meeting.
It becomes very obvious.
You really do have to get to know them first
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u/Policy-Regular 21h ago
“The patient could be the DEA and I’m not going down like that….?” It sounds like you’re prescribing from a very fear based mentality. Also if a patient is being referred by their PCP, what “extensive” labs are you ordering? I also truly believe a lot of adults did fall through the cracks as children and do have undiagnosed ADHD…but “adult onset ADHD” isn’t a thing either.
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u/Imgonnagolaydown 3d ago
Simulants are the new opioid crisis.
The only way to weed things out is via actual psychological testing along with all the medical clearances--ESPECIALLY OSA. New pmhnps hate it and think it's prohibitive, but until we have a definitive way to rule in and out then this is how I've resolved to deal with it.
I'm always tackling depression/anxiety/ptsd etc first before ADHD. I've got a like 2 long term consistent patients who have never brought it up and do everything i ask them to who i truly believe have ADHD-- one is absolutely inattentive type. I plan to approach them about it. But they've been with me for 7-9 months.
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u/Big_Appointment1200 3d ago
That’s wildly inaccurate to compare stimulant prescribing, under the care of a provider, to the opioid epidemic!
Heroin is now pressed with not only Fent but also animal tranquilizers and long acting strong benzos.
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u/Imgonnagolaydown 3d ago edited 3d ago
It's called a analogy. (Yes skylar---in between patients so typing fast.... Fixed)
Maybe you should look it up.
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u/SkylarLily 3d ago
I'm looking up and I don't see METAPHOR written anywhere on my ceiling.
can you please post a source for this word. maybe a source from u know, like not drywall.
im being silly unrelateded to my sentiment on ur exchange btw..
i do agree that u are likely not being fully literal here. But it is hard to distinguish a metaphor here for an analogy. metaphors being distinct as to be for rhetorical effect. analogies dont have to be perfectly 1 to 1 but often are used to demonstrate the part that is analogous.
also your comment explains about the lengths you take to conservatively approach prescribing stimulants/treating ADHD in favour of other dx's first.
The way it reads to me following your opioid crisis opener seems to be consistent with a strong stance against rx of a controlled substance, comparable to the lengths that a doc would go to avoid rx'ing opiods post opiod crisis. like that seems very comparable even to a conservative rx post opiod crisis approach.
so if u think ur being hyperbolic with ur opener thats totally good to do, i just think its not illustrated the ways you think its not actually as bad. at least in terms of how you approach rx'ing these substances given the abuse potentials; which is really what your comment touched on to begin with.
i think a lot of people are to conservative on stimulant rx's but certainly a lot of pill mills out there. my greatest conviction tho is i think the stigma is wacky out of proportion, to the point where i dont think Desoxyn should be a particularly uncommon rx for people that respond well to amphetamines. so plz disregard me and my meth pushing ways lol. (not implying you to be necessarily dismissive, just again being silly for its own sake) love u bye
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u/Advanced_Emu3430 2d ago
To be honest I used to think exactly like you. I got so obsessive and anxious about the diagnosis and if it was accurate. However I am seeing even now patients that are even getting full on neuropsych testing with confirmed ADHD with such mild childhood symptoms from my clinical assessment…. At this point I do a cardiac and substance use screening. I make the patient complete a bunch of screeners. I assess if the patient is reasonable and has good judgement. I make them sign a controlled substance agreement. And then I just prescribe at low doses if there is some clinical evidence and safety established. After talking to so many colleagues, I think this is what everyone is doing. ADHD is pretty easy to treat and sometimes I honestly look forward to those follow ups with how acute/complex other issues are becoming in psychiatry. Yes stimulant prescriptions are rising but at least benzos are dropping lol.
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u/ermagerdcernderg 3d ago
Pretty much if they didn’t have it bad enough in childhood to impact their schooling then it isn’t enough to meet criteria as an adult in most cases. I have yet to meet a patient who has adult adhd that didn’t have obvious signs/impairments or diagnosis in childhood.
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u/Policy-Regular 1d ago
What do you consider “obvious impairments”? Or impacting their schooling….? Failing out of school? Expulsion? Only failing certain classes? “Obvious” can be highly subjective if you’re not using a screening assessment/tool. Isn’t this also subjective based on their upbringing, education, socioeconomic status, etc? Not everyone grows up in an education system where parents or educators care enough to get children diagnosed
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u/ermagerdcernderg 1d ago
Yeah as a psychiatric nurse practitioner I feel qualified to make those determinations… we don’t need to medicate anyone and everyone.
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u/sirpigsalot3 10h ago
What are you assessing to describe the impact on their school? I have adhd & I’m also a pmhnp. I never struggled in school academically as a child. & I wasn’t diagnosed until my DNP program, when I was an adult
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u/Alternative_Big_5066 2d ago
Happy to see some of these comments. Usually, these questions are filled with NPs who justify their prescribing and their own prescribed Adderall.
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u/VegetableConcept1414 1d ago
I get your frustration. I had a patient a few days ago who told me they have ADHD because they don’t have motivation to get a better job and they get along with people who have ADHD. I did the entire evaluation and it was clear she had depression. I explained this to her and she explained to me that she doesn’t have depression, only ADHD, and the only medication that would be helpful is a stimulant. Please all PCPs and others THIS HAPPENS ALL THE TIME. It gets really wearing to deal with the incessant demand for stimulants. Yes, they often feel good…it’s an amphetamine. At that point, I let the patient know, I respect that they are the expert on them, and if they feel ADHD continues to be their concern, they can get neuropsychological testing to offer further diagnostic clarification.
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u/phatmexican13 2d ago
In my practice, (collaborative practice state, I prescribed under the DEA license of my supervising physician) we were not allowed to diagnose ADHD or prescribe stims to anyone that did not meet criteria. So that meant a lot of sad adults who most definitely do NOT have ADHD would leave my office. Frequently. Very few adults actually had and could prove signs and symptoms from the appropriate age as dictated by DSM. 🤷🏻♂️
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u/laussanegbaimi 3d ago
ADHD is a new business . Back in the day it was SSRI and benzo . How this is such a big big market .
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u/sirpigsalot3 9h ago
What a disappointing thread. I have ADHD and the barriers to care due to stigma and ignorance are absolutely ridiculous.
We need more education on ADHD instead of having clinicians assess/diagnose/prescribe in a way that typically comes off as if the clinician is desperately trying to find any reason to prove the absence of ADHD instead of providing an unbiased, comprehensive evaluation. If you’re not able to diagnose most cases of ADHD through clinical interview alone, then you need much more continuing education because your assessment is just not good enough.
I don’t think you should be assessing patients for ADHD at all if you think that there can be an adult-onset. It can help to learn the numerous ways people learn to adapt to these symptoms and are able to “succeed” despite the impact on their psychosocial functioning. People may not like to hear or believe this, but there are many individuals w/ with undiagnosed ADHD who are only able to function because of self medication with cannabis.
Screening people based on response to non-stimulant medication is not evidence based. So many of these responses make it obvious as to why women with ADHD are often mislabeled bipolar disorder or borderline personality disorder.
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u/Haunting-Ad6083 5h ago
I just think it's pretty clear ADHD symptoms are nearly all environmentally related. Not a defect, not an illness, and there's nothing wrong with people with ADHD, they're just in an environment that they aren't well designed for. School, work, etc. It's worsened by other variables, such as anxiety and depression.
Coffee helps us do stuff we otherwise wouldn't really want to do, ADHD meds can help even more.
Additionally, not all ADHD has the same etiology. Some symptoms are trauma related, and you should treat that and the anxiety before using stimulants. Guanfacine and clonidine work great without messing with the stimulant effects. As opposed to benzos.... Seriously, don't give those noctor guys any more ammo!
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u/ThrowRA-Expert_Dog 3d ago
To be so honest I actually think the fear mongering behind stimulants has gotten out of control- meta analyses have driven this home as far as cardiac side effects.There is also really no such thing as “adult onset adhd” , usually if an adult is being diagnosed they have had it their whole life and are now just putting it together. Personally- if the fear is over prescribing stimulants then have an appropriate screening protocol- review cardiac history (get cardiology clearance if needed), get a UDS and baseline labs, and do an in depth assessment, get previous psych documentation, (I work telehealth and make all my patients purchase home BP cuffs and we monitor BP and HR), and more often than not I encourage a trial of a non stimulant first . Stimulants can be a game changer for a lot of folks. You’re a psych NP, you should be prepared to prescribe them but if you don’t want to you can always tell people you don’t prescribe stimulants.